A list of the most recent deficiencies for Bourne Manor Extended Care Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-28 | 2023-12-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-28 | 2023-12-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-28 | 2023-12-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-28 | 2023-12-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-31 | 2023-12-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-31 | 2023-12-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-31 | 2023-12-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-31 | 2023-12-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-31 | 2023-12-09 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-10-12 | 2023-11-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-12 | 2023-11-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-12 | 2023-11-17 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-12 | 2023-11-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-12 | 2023-11-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-12 | 2023-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-12 | 2023-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-12 | 2023-11-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-12 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-17 | N |
| Keep all essential equipment working safely. | Health | 2023-10-12 | 2023-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-12 | 2023-07-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-04 | 2022-01-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-04 | 2022-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2022-01-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-04 | 2022-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2022-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-22 | 2022-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2022-01-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-22 | 2022-01-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-04 | 2021-12-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-11-04 | 2021-12-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-04 | 2021-12-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-11-04 | 2021-12-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2021-12-27 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-11-04 | 2021-12-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-04 | 2021-12-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-04 | 2021-12-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-04 | 2021-12-27 | N |
| Post nurse staffing information every day. | Health | 2021-11-04 | 2021-12-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-04 | 2021-12-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-04 | 2021-12-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-04 | 2021-12-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-04 | 2021-12-27 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-11-04 | 2021-12-27 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-04 | 2021-12-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-10 | 2021-12-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-10 | 2021-12-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-10 | 2021-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-10 | 2021-12-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-29 | 2021-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-01 | 2021-06-04 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-27 | 2020-04-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-27 | 2020-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-27 | 2020-04-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-21 | 2020-03-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-01-21 | 2020-03-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-21 | 2020-03-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-01-21 | 2020-03-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-21 | 2020-03-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-21 | 2020-03-16 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-21 | 2020-03-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-21 | 2020-03-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-21 | 2020-03-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-21 | 2020-03-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-21 | 2020-03-16 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-21 | 2020-03-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-21 | 2020-03-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-21 | 2020-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-21 | 2020-03-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-21 | 2020-03-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-21 | 2020-03-16 | N |
| Provide or obtain dental services for each resident. | Health | 2020-01-21 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-21 | 2020-03-16 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-21 | 2020-03-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-21 | 2020-03-16 | N |
| Keep all essential equipment working safely. | Health | 2020-01-21 | 2020-03-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-21 | 2020-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-27 | 2020-03-10 | N |
